Regulation and regulatory effectiveness in public health

Abstract

Regulation for health in the modern era has its foundations in the English Public Health Act of 1848. Early legislation was concerned with controlling environmental causes of disease. However, the focus on regulation today within health departments has diminished, displaced by a focus on services and related programs. The regulatory debate is now centred on what degree of protection, or safety margin, is required, and how regulatory efficiency may be improved. The example of tobacco control is reviewed to show how regulation can play a large role in chronic disease control, and consideration given to how regulatory tools could be further diversified and regulatory effectiveness improved. Andrew Penman The Cancer Council NSW Email: andrewp@nswcc.org.au Population health goals in the early 21st century mostly focus on reducing mortality from chronic disease and the compression of associated morbidity.1 These conditions share common proximate risk factors rooted in lifestyle. Health promotion developed largely to change lifestyle behaviours through education and social change – a change mediated though information, services, the built environment and organisational practice. In this paradigm, the role of health protection, or health regulation, has been minimised, and the title given to the frontline warrior of the first public health act – Inspector of Public Nuisances – seems out of place in these more egalitarian times. Developments in health regulation Health promotion has resulted in a more explicit understanding of the diversity of the health environment and recognition that individual behaviour is profoundly affected by social context. Human behaviour and the environment interact, and environmental regulation can play an important role in chronic disease control. This understanding has required an evolution in the philosophy and practice of health regulation. The story of tobacco control illustrates the role that regulation can play in modifying behaviours and lifestyles. One development is in our understanding of chronic disease. Traditional health protection excelled at elimination of a hazardous agent at source. In chronic disease, specific regulatory measures are crafted to eliminate not the proximate cause of disease, but any of a number of contributory causes. Taken as a whole, these measures may be demonstrably effective in reducing risk, but the contribution of any single measure may be moderate to minor. Advertising bans, tax increases, smoke-free public places, on-pack warnings and point-of-sale restrictions have all contributed to smoking abatement. Although evidence can be adduced to demonstrate short-term impact on behaviour, it is more difficult to isolate the impact of each measure on smoking prevalence, and especially to predict this in advance of a regulatory decision.2 The statement, “Why don’t you just ban the stuff?”, heard in popular discourse on tobacco illustrates the public expectation that our measures should be more decisively effective. Another development has been to recruit regulatory instruments from outside the health sector, appropriate to the environmental–behavioural goals. In tobacco control, taxing 10.1071/NB08055 PERSPECTIVE